Horizon NJ Health MLTSS Service Descriptions

These MLTSS Service Descriptions provide a comprehensive overview of the services available to

Horizon NJ Health MLTSS members that are furnished by MLTSS non-medical ancillary providers. Benefits are established by the State of New Jersey and are subject to change.

Adult Family Care

Adult Family Care (AFC) enables up to three unrelated individuals to live in the community in the primary residence of a trained caregiver who provides support and health services for the resident. AFC providers may provide personal care, meal preparation, transportation, laundry, errands, housekeeping, socialization and recreational activities, monitoring of participant's funds when requested by the participant, up to 24 hours a day of supervision and medication administration.

Service Limitations:

Individuals that opt for AFC are not eligible for Personal Care Assistant services, Chore Service, Home-Delivered Meals, Home-Based Supportive Care, Caregiver/Participant Training, Assisted Living, or the Assisted Living Program. Those services would duplicate services integral to and inherent in the provision of AFC services. A person may not receive long-term nursing home care at the same time as AFC. The individual service recipient or authorized representative is responsible to pay the cost of room and board.

AFC members may attend Social Adult Day Care two (2) days per week.

Provider Specifications:

• Licensed AFC Sponsor Agency (Agency)
• Licensed by Health Facilities Evaluation and Licensing (HFEL)

Assisted Living Services

Assisted Living Services (ALS) are a coordinated array of supportive personal and health services and medication administration. These services are available 24 hours a day to residents who have been assessed to need these services – including persons who require a nursing home level of care. Assisted living services include personal care and medication oversight and administration throughout the day. A planned, diversified program of resident activities shall be offered daily for residents, including individual and/or group activities, onsite or offsite, to meet the individual needs of residents.

Assisted living facilities also either arrange or provide for transportation that is specified in the Plan of Care and periodic nursing evaluations. Assisted living promotes a member's self-direction and participation in decisions that emphasize independence, individuality, privacy, dignity and homelike surroundings.

An Assisted Living Residence (ALR) is a facility that is licensed by the Department of Health to provide apartment-style housing and congregate dining and to ensure that assisted living services are available when needed, for four or more adult persons unrelated to the proprietor. Apartment units within the ALR offer, at a minimum, one unfurnished room, a private bathroom, a kitchenette, and a lockable door on the unit entrance. Residents in ALRs have access to both their own living unit's kitchen 24 hours a day, seven days a week, and to facility food and beverages 24 hours a day, seven days a week.

A Comprehensive Personal Care Home (CPCH) is a facility that is licensed by the Department of Health to provide room and board and to ensure that assisted living services are available when needed to four or more adults unrelated to the proprietor. Residential units in CPCHs house no more than two residents and have a lockable door on the unit entrance. Residents in CPCHs have access to facility food and beverages 24 hours a day, seven days a week and, if equipped, access to their own unit's food preparation area.

Service Limitations:

Individuals that opt for ALS in an ALR/CPCH do NOT receive: Personal Care Assistant (PCA) services, Adult Day Health Services (ADHS), AFC, Assisted Living Program, Environmental Accessibility Adaptations, Chore Services, Personal Emergency Response Services, Home-Delivered Meals, Caregiver/Participant Training, Adult Day Health Services, Social Adult Day Care, Attendant Care,

Home-Based Supportive Care, or Respite, as the above would duplicate services integral to and inherent in the provision of ALS. Individuals in an ALR/CPCH are responsible for paying their room and board costs.

Provider Specifications:

Assisted Living Facility licensed by the Department of Health pursuant to N.J.A.C. 8:36 as an Assisted Living Facility. Appropriateness for this type of housing is subject to screening through the housing screening process.

Must meet licensing requirements, as applicable per:

• N.J.A.C. 8:34 - Rules for Licensing Nursing Home Administrators and Rules Regulating the Nursing Home Administrators Licensing Board
• N.J.A.C. 8:36 - Standards For Licensure of Assisted Living Residences, Comprehensive Personal Care

• Homes and Assisted Living Programs
• N.J.A.C. 8:43E - Standards For Licensure of Residential Health Care Facilities, General Licensure Procedures and Enforcement of Licensure Regulations
• N.J.A.C. 8:43I - Criminal Background Investigations: Nurse Aides, Personal Care Assistants and Assisted Living Administrators

Assisted Living Program (ALP)

ALP provides assisted living services to the tenants/ residents of certain publicly subsidized housing buildings. ALPs are available in some subsidized senior housing buildings. Each ALP provider shall be capable of providing or arranging for the provision of assistance with personal care, and of nursing, pharmaceutical, dietary and social work services to meet the individual needs of each resident.

ALP includes personal care, homemaker, chore, and medication oversight and administration throughout the day.

Individuals receiving services from an ALP reside in their own independent apartments. The individual is responsible for his or her own rent and utility payments as defined in a lease with the landlord. Individuals are also responsible for the cost of meals and other household expenses.

Having an ALP provider offers the subsidized housing tenants the opportunity to remain in their own apartments with the support of others, while maintaining their independence and dignity.

Participation in the services of an ALP is voluntary on the part of any tenant of any ALP contracted publicly subsidized housing building.

The ALP is to make available dining services and/or meal preparation assistance to meet the daily nutritional needs of residents.

ALP providers work with participants to ensure a strong sense of connectedness in each apartment community as well as with the larger communities in which they are located. Individuals may participate in tenant/resident meetings, attend community-based civic association meetings and plan recreational activities. Sometimes, ALP providers host community health screening events to encourage wellness for the tenant population at large.

By state regulation, ALP providers shall have written policies and procedures for arranging resident transportation to and from health care services provided outside of the program site and shall provide reasonable plans for security and accountability for the resident and his or her personal possessions. ALP providers shall develop a mechanism for the transfer of appropriate resident information to and from the providers of service, as required by individual residents and as specified in their service plans.

ALP participants, not ALR or CPCH participants, may attend Social Adult Day Care 2 (two) days a week; (3) three days with prior authorization.

Service Limitations:

Individuals that opt for ALP do NOT receive: Personal Care Assistant (PCA) services, Chore Service, Home-Based Supportive Care, Caregiver/Participant Training, Assisted Living, or Adult Family Care as they would duplicate services integral to and inherent in the provision of ALP services. The subsidized housing provider is responsible for Environmental Accessibility Adaptations.

A person enrolled in the ALP is NOT permitted to attend Adult Day Health Services (also called medical day care) as it would duplicate an ALP service as required by N.J.A.C. 8:36-23.14(a).

The ALP provider must agree to accept the individual in the facility as a Medicaid MLTSS participant.

Provider Specifications:

Assisted Living Facility licensed by the Department of Health pursuant to N.J.A.C. 8:36 as an Assisted Living Facility. Appropriateness for this type of housing is subject to screening through the housing screening process. Must meet licensing requirements, as applicable per:

• N.J.A.C. 8:34 - Rules for Licensing Nursing Home Administrators and Rules Regulating the Nursing

• Home Administrators Licensing Board
• N.J.A.C. 8:36 - Standards For Licensure of Assisted Living Residences, Comprehensive Personal Care
• Homes and Assisted Living Programs
• N.J.A.C. 8:43E - Standards For Licensure of Residential Health Care Facilities, General Licensure Procedures and Enforcement of Licensure Regulations
• N.J.A.C. 8:43I - Criminal Background Investigations: Nurse Aides, Personal Care Assistants and Assisted Living Administrators

TBI Behavioral Management (Group and Individual)

Traumatic Brain Injury (TBI) Behavioral Management is a daily program provided by, and under the supervision of, a licensed psychologist or board-certified/board-eligible psychiatrist and by trained behavioral aides designed to service recipients who display severe maladaptive or aggressive behavior, which is potentially destructive to self or others. The program, provided in the home or outside the home, is time-limited and designed to treat the individual and caregivers, if appropriate, on a short-term basis. Behavioral programming includes a complete assessment of the maladaptive behavior(s); development of a structured behavioral modification plan; implementation of the plan; ongoing training and supervision of caregivers and behavioral aides; and periodic reassessment of the plan.

The goal of the program is to return the individual to the prior level of functioning, which is safe for him/her and others.

Service Limitations:

Entry to this service is based on medical necessity criteria as defined in the contract. The individual must have a diagnosis of acquired, non-degenerative TBI or be a former TBI waiver participant who transitions into MLTSS. Program enrollment requires prior evaluation and recommendation from a board-certified and eligible psychiatrist, a licensed neuropsychologist or neuropsychiatrist with subsequent consultation by same on an as-needed basis.

Provider Specifications:

• Board-certified and board-eligible psychiatrist
• Clinical psychologist
• Mental health agency
• Rehabilitation hospital
• Community Residential Services (CRS) provider
• Post-acute non-residential rehabilitative services provider agency

TBI Community Residential Services (CRS)

A package of services provided to a participant living in the community, residence-owned, rented or supervised by a CRS provider. The services include personal care, companion services, chore services, transportation, night supervision and recreational activities. A CRS is a participant's home. The CRS provider is responsible for coordinating the service to ensure the participant's safety and access to services as determined by the participant and Care Manager. Participants are assigned one of three levels of supervision. These levels are determined by the dependency of the participant. The Care Manager, in conjunction with CRS staff, evaluates participant, using the “Level of Care Guidelines for CRS” form as a guide.

Service Limitations:

The individual must have a diagnosis of acquired, non-degenerative TBI or be a former TBI waiver participant who is transitioning to MLTSS. The level of assessment is assessed minimally on an annual basis, more frequently if there is a change in participants' care. Only one level of service can be billed per 24-hour period (12 a.m. to 11:59 p.m.)

• The participant must have a diagnosis of TBI and meet MLTSS Nursing Facility Level of Care
• The participant or responsible party must pay room and board costs
• The participant must agree to receive the therapy services of the CRS provider

Provider Specifications:

• Current license per N.J.A.C 10:44C to operate as a group home for individuals with a diagnosis of TBI

Community Transition Services

Those services provided to a participant to aid in transition from institutional settings to his/her own home in the community through coverage of non-recurring, one-time transitional expenses. This service is provided to support the health, safety and welfare of the participant. Allowable expenses are those necessary to enable a person to establish a basic household that do not constitute room and board and may include:

• Security deposits that are required to obtain a lease on an apartment or home
• Essential household furnishings and moving expenses required to occupy and use a community domicile, including furniture, window coverings, food preparation items and bed/bath linens
• Set-up fees or deposits for utility or service access, including telephone, electricity, heating and water
• Services necessary for the individual’s health and safety such as pest eradication and one-time cleaning prior to occupancy
• Necessary accessibility adaptations to promote safety and independence
• Activities to assess need, arrange for and procure needed resources

Service Limitations:

• Limit of up to $5,000 Community Transition Services do not include:
• Residential or vehicle modifications
• Recreational items such as televisions, cable television access or video players
• Monthly rental or mortgage expenses; payment for security deposit is not considered rent
• Recurring expenses such as food and regular utility charges
• Payment for room and board
• Are one time per the life of the individual
• Are furnished only to the extent that they are reasonable and necessary as determined through the service plan development process, clearly identified in the service plan, and the person is unable to meet such expense or when the services cannot be obtained from other sources
• Service is based on identified need as indicated in the Plan of Care

Nursing Facility Services (Custodial)

A nursing facility (NF) is a facility that is licensed (per N.J.A.C 8:39 and 8:85) to provide health care under medical supervision and continuous nursing care for 24 or more consecutive hours to two or more patients who do not require the degree of care and treatment which a hospital provides and who, because of their physical or mental condition, require continuous nursing care and services above the level of room and board. NF residents are those individuals who require services which address the medical, nursing, dietary and psychosocial needs that are essential to obtaining and maintaining the highest physical, mental, emotional and functional status of the individual. Care and treatment shall be directed toward development, restoration, maintenance, or the prevention of deterioration. Care shall be delivered in a therapeutic health care environment with the goal of improving or maintaining overall function and health status. The therapeutic environment shall ensure that the individual does not decline (within the confines of the individual's right to refuse treatment) unless the individual’s clinical condition demonstrates that deterioration was unavoidable.

All Medicaid participating NFs shall provide or arrange for services in accordance with statutory and regulatory requirements under 42 CFR 483 and Department of Health licensing rules at N.J.A.C. 8:39.

Reimbursement of NF services is discussed in N.J.A.C. 8:85-3. NF services shall be delivered within an interdisciplinary team approach. The interdisciplinary team shall consist of a physician and a registered nurse and may also include other health professionals as determined by the individual's health care needs. The interdisciplinary team performs comprehensive assessments and develops the interdisciplinary care plan.

Service Limitations:

The individual must meet Nursing Facility Level of Care as determined and/or authorized by the NJ Department of Human Services, Office of Community Choice Options or their designee.

Provider Specifications:

• Current license to operate as a Nursing Facility in NJ as per the Department of Health’s N.J.A.C. 8:39 and 8:85

TBI Occupational Therapy (Group and Individual)

For the purpose of habilitation and the prevention of loss of function. This service is available only after rehabilitation is no longer available or viable. MLTSS will include rehabilitation therapies for an individual with a TBI diagnosis. CPT codes are to be used for these services.

Provider Specifications:

• A rehabilitation hospital
• Community Residential Services (CRS) provider
• Licensed, certified home health agency
• Post-acute, non-residential rehabilitative services provider agency

TBI Cognitive Therapy (Group and Individual)

Therapeutic interventions for maintenance and prevention of deterioration, which include direct retraining, use of compensatory strategies, use of cognitive orthotics and prostheses, etc. Activity type and frequency are determined by assessment of the participant, the development of a treatment plan based on recognized deficits, and periodic reassessments. Cognitive therapy can be provided in various settings, including but not limited to the individual's own home and community, outpatient rehabilitation facilities, or residential programs.

This service may be provided by professionals with the credentials, training, experience and supervision noted in Provider Specifications.

Service Limitations:

The individual must have a diagnosis of acquired, non-degenerative TBI or formerly a TBI waiver participant who transitions to MLTSS.

Provider Specifications:

• Minimum of a master's degree or a degree in an allied health field from an accredited institution or holds licensure and/or certification
• Minimum of a bachelor's degree from an accredited institution in an allied health field where the degree is sufficient for licensure, certification or registration or in fields where licensure, certification or registration is not available (e.g., special education)
• Applicable degree programs including but not limited to communication disorders (speech), counseling, education, psychology, physical therapy, occupational therapy, recreation therapy, social work and special education
• Certified Occupational Therapy Assistants (COTAs) and Physical Therapy Assistants (PTAs) may provide this service only under the guidelines described in the New Jersey practice acts for occupational and physical therapists
• Staff members who meet the above-mentioned degree requirements, but are not licensed or certified, may practice under the supervision of a practitioner who is licensed and/or meets the criteria for certification by the Society for Cognitive Rehabilitation (actual certification is not necessary so long as criteria is met)

Supervision:

• This service must be coordinated and overseen by a provider holding at least a master's degree. Provided by a professional that is licensed or certified. The master's level provider must ensure that bachelor's level providers receive the appropriate level of supervision, as delineated below
• Supervision for providers who are not licensed or certified is based on the number of years of experience
• For staff with less than one year of experience: four hours of individual supervision per month
• For staff with one to five years of experience: two hours individual supervision per month
• For staff with more than five years of experience: one hour per month

All individuals who provide or supervise the service must complete six hours of relevant ongoing training in cognitive therapy and/or brain injury rehabilitation. Training may include, but is not limited to, participation in seminars, workshops, conferences and in-services.

Caregiver Participant Training

Training/instruction to a client and/or caregiver in either a one-to-one or group situation to teach a variety of skills necessary for independent living, including but not limited to: coping skills to assist the individual in dealing with disability; coping skills for the caretaker to deal with supporting someone with long-term care needs; and skills to deal with care providers and attendants. Examples include seminars on supporting someone with dementia and seminars to support someone with mobility difficulties. Training needs must be identified through comprehensive evaluation/re-evaluation or in a professional evaluation and must be identified in the approved Plan of Care as a required service.

Chore Services

Services needed to maintain the home in a clean, sanitary and safe environment. The chores are non-continuous, non-routine heavy household maintenance tasks intended to increase the member's level of safety. Chore services include cleaning appliances; cleaning and securing rugs and carpets; washing walls; windows, scrubbing floors; cleaning attics and basements to remove fire and health hazards; clearing walkways of ice, snow, leaves; trimming overhanging tree branches; replacing fuses, light bulbs, electric plugs, frayed cords; replacing door locks, window catches; replacing faucet washers; installing safety equipment; seasonal changes of screens and storm windows; weather stripping around doors; and caulking windows.

Home-Delivered Meals

Deliver nutritionally balanced meals to a member's home when this meal provision is more cost-effective than having a personal care provider prepare the meal. These meals do not constitute a full nutritional regimen, but each meal shall provide at least 1/3 of the current Recommended Dietary Allowance (RDA) established by the Food & Nutrition Board of the National Academy of Sciences and National Research Council.

Residential Modifications

Those physical modifications/adaptations to a participant's private primary residence required by his/her Plan of Care, which are necessary to ensure the health, welfare and safety of the individual, or which enable him/her to function with greater independence in the home or community and without which the individual would require institutionalization. Such adaptations may include the installation of ramps and grab bars, widening of doorways, modifications of bathrooms, or installation of specialized electrical or plumbing systems that are necessary to accommodate the medical equipment and supplies which are needed for the health, safety and welfare of the individual. Residential modifications are limited to $5,000 per calendar year, $10,000 lifetime.

Non-Medical Transportation

Service offered to enable individuals to gain access to community services, activities and resources specified in the Plan of Care. This service is offered in addition to medical transportation required under 42 Code of Federal Regulations 431.53 and transportation services under the State plan, defined at 42 Code of Federal Regulations 440.170(a) (if applicable), and shall not replace them.

Transportation services shall be offered in accordance with the individual's Plan of Care. Transportation is a service that enhances the individual's quality of life.

An approved provider may transport the participant to locations including but not limited to: shopping, beauty salon, financial institution, or religious services of his or her choice.

Service Limitations:

Services are limited to those that are required for implementation of the Plan of Care.

Whenever possible, family, neighbors, friends, public transit, tickets or community agencies, which can provide this service without charge, will be utilized.

Provider Specifications:

• Vehicle must be maintained in proper operating condition and must meet the requirements of

New Jersey regulations, as evidenced by a valid inspection sticker.

• Owner must have proof of liability insurance coverage for the vehicle.
• Owners and drivers are required to undergo civil and criminal background checks.
• Evidence of Insurance, i.e. Declaration Page from insurance company, must be produced.
• Provide description of vehicles used in service and copies of any required licenses.
• Vehicle appropriately registered, inspected and insured; Driver licensed to operate the vehicle.
• Provides proof of New Jersey Business Authority, e.g., tax certificate or trade name registration.
• Provides Fee Schedule.
• Participant-Directed Provider.

Vehicle Modifications

The services include needed vehicle modification (such as electronic monitoring systems to enhance beneficiary safety, mechanical lifts to make access possible) to a participant or family vehicle as defined in an approved Plan of Care. Modifications must be needed to ensure the health, welfare and safety of a participant or which enable the individual to function more independently in the home or community. All services shall be provided in accordance with applicable State motor vehicle codes. The vehicle must be registered in New Jersey and must be owned by the member or the member’s authorized representative.

Medication Dispensing Device (MDD) Set Up and Monthly Monitoring

This may include an electronic medication-dispensing device that allows for a set amount of medications to be dispensed as per the dosage instructions. If the medication is not removed from the unit in a timely manner, the unit will “lock” that dosage, not allowing the participant access to the missed medication. Before locking, the unit will use a series of verbal and/or auditory reminders that the participant is to take his or her medication. If there is no response, a telephone call will be made to the participant, participant's contact person and case management site in that order until a “live” person is reached. Installation, upkeep and maintenance of device/systems are provided.

Service Limitations:

Per Medical Necessity as defined in the MCO contract, MDD is for an individual who lives alone or who is alone for significant amounts of time per the Plan of Care. Individuals might not have a regular care giver for extended periods of time or would require extensive routine supervision.

Personal Emergency Response System (PERS) Set Up and Monitoring

PERS is an electronic device that enables participants at high risk of institutionalization to secure help in an emergency. The individual may also wear a portable “help” button to allow for mobility. The system is connected to the person's phone and is programmed to signal a response center once a “help” button is activated. The response center is staffed by trained professionals. The service consists of two components both of which are managed by the PERS contractor; first is the initial installation of the equipment, and the second is the monitoring of the service by staff at the response center. The addition of the fiscal intermediary is the modification to the provider specifications. Previously, the provider of the specific service was required to execute a purchase agreement with the case management agency; now that agreement is between the fiscal intermediary and the service provider.

Service Limitations:

Per Medical Necessity as defined in the MCO contract, PERS is for an individual who lives alone for significant amounts of time per the Plan of Care. Individual might not have a regular caregiver for extended periods of time or would require extensive routine supervision.

Respite (Daily and Hourly)

Services provided to participants unable to care for themselves that are furnished on a short-term basis because of the absence or need for relief of an unpaid, informal caregiver (those persons who normally provide unpaid care) for the participant. In the case where a person is in the personal preference program or is self-directing services, respite may be used to provide relief for the temporary absence of the primary paid caregiver. Federal financial participation is not claimed for the cost of room and board except when provided as part of respite care furnished in a facility approved by the state that is not a private residence.

Service Limitations:

Respite is limited to up to 30 days per participant per calendar year. If respite is provided in a nursing home, room and board charges are included in the Institutional Respite rate. Respite will not be reimbursed for individuals who reside permanently in a CRS setting, an ALR or CPCH or for individuals that are admitted to a nursing facility.

Respite care shall not be reimbursed as a separate service during the hours the participant is in either Adult Day Health Services or Social Adult Day Care.

Services excluded from additional billing while simultaneously receiving Respite care include: Chore,

Home-Based Supportive Care, Home-delivered Meals, and Personal Care Assistant services. Sitter, live-in or companion services are not considered Respite services and cannot be authorized as such. Respite services are not provided for formal, paid caregivers (e.g., Home Health or Certified Nurse Aides). Respite services are not to be authorized due to the absence of those persons who would normally provide paid care for the participant.

Eight or more hours of respite in one 24-hour period provided by the same provider is the DAILY respite service.

Provider Specifications:

Respite care may be provided in the following location(s):

• Individual's home or place of residence
• Medicaid-certified nursing facility that has a separate Medicaid provider number to bill for Respite
• Another community care residence that is not a private residence including: an ALR, a CPCH or an Adult Family Care (AFC) Home

The 21st Century Cures Act requires the use of Electronic Visit Verification (EVV) for all Medicaid-funded, personal-care services. EVV is a web-based system that verifies when a provider documents the precise time a service visit begins and ends, and the location where the service is being provided. Learn more about EVV requirements.

Home-Based Supportive Care Services

Home-Based Supportive Care (HBSC) services are designed to assist MLTSS participants with their

Instrumental Activities of Daily Living (IADL) needs. HBSC services are available to individuals whose Activities of Daily Living (ADL) needs are provided by non-paid caregivers such as a family member or as a wraparound service to non-Medicaid programs such as those administered by the Department of Veterans Affairs that are assisting participants with their ADL health-related tasks. HBSC services must address IADL deficits identified through the NJ Choice comprehensive assessment process and go beyond “health-related” services.

HBSC is distinct from the State Plan service of Personal Care Assistant in that it does not include “hands-on personal care.” According to N.J.A.C. 10:60-1.2, Personal Care Assistant (PCA) services means “health-related tasks” performed by a qualified individual in a beneficiary's home, under the supervision of a registered nurse, as certified by a physician in accordance with a beneficiary's written Plan of Care.

HBSC services include, but are not limited to, the following: meal preparation, grocery shopping, money management, light housework or laundry.

Service Limitations:

HBSC services are not available for those who have chosen ALR, CPCH, ALP. Since the PCA State Plan

Service can assist with IADL, HBSC is offered only when ADL-related tasks are provided by a caregiver or another non-Medicaid program.

Provider Specifications:

• Licensed home health agency
• Licensed health care service firm
• Licensed employment agency or temporary help agency
• Congregate Housing Services Program
• Licensed hospice provider
• Participant-directed provider

Electronic Visit Verification (EVV) is required for all Medicaid-funded, personal-care services. Learn more about EVV requirements.

Private Duty Nursing (Adult)

Private Duty Nursing shall be a covered service only for those beneficiaries enrolled in MLTSS and the DDD Supports Plus PDN program operated by DDD. When payment for private duty nursing services is being provided or paid for by another source, the benefit of private duty nursing hours shall supplement the other source up to a maximum of 16 hours per day, including services provided or paid for by the other sources, if medically necessary, and if cost of service provided is less than institutional care.

The 16 hours per day limitation for PDN services noted above and below shall not apply to children under the age of twenty one years who are eligible for Medicaid/NJ FamilyCare EPSDT services.

Service Limitations:

Per Medical Necessity as defined in the contract. Private Duty Nursing services are provided in the community only (the home or other community setting of the individual), and not in hospital inpatient or nursing facility settings. Private Duty Nursing services are a State Plan benefit for children under the age of 21. EPSDT services must be exhausted before accessing MLTSS PDN. Children who meet the eligibility criteria for MLTSS services contained in this dictionary shall not have their access to Medicaid

EPSDT services limited through the language contained in this document. For adults over the age of 21, private duty nursing is provided under the MLTSS benefit and through the DDD Supports Plus program.

Persons meeting NF level of Care are eligible to receive private duty nursing. Private Duty Nursing criteria is based on medical necessity, and is prior approved by the MCO in a plan of care. Private duty nursing is individual, continuous, ongoing nursing care in the home, and is a service available to a beneficiary only after enrollment in MLTSS or, in the case of DDD Supports Plus PDN, being determined as meeting nursing facility level of care.

Approval is provided by the MCO for MLTSS beneficiaries. Approval is provided by the state for fee-for-service beneficiaries.

Provider Specifications:

• RN or an LPN under the direction of the enrollee's physician.

PDN services shall be provided by a licensed home health agency, voluntary non-profit homemaker agency, private employment agency and temporary-help service agency approved by DMAHS/the MCO. The voluntary nonprofit homemaker agency, private employment agency and temporary help-service agency shall be accredited, initially and on an ongoing basis, by at least one of the following accrediting entities:

• Commission on Accreditation for Home Care, Inc.
• Community Health Accreditation Program
• The Joint Commission
• National Association for Home Care and Hospice

Social Adult Day Care

Social Adult Day Care (SADC) is a community-based group program designed to meet the non-medical needs of adults with functional impairments through an individualized Plan of Care. SADC is a structured comprehensive program that provides a variety of health, social and related support services in a protective setting during any part of a day, but less than 24-hour care. Individuals who participate in SADC attend on a planned basis during specified hours. SADC assists its participants to remain in the community, enabling families and other caregivers to continue caring at home for a family member with impairment. SADC services shall be provided for at least five consecutive hours daily, exclusive of any transportation time, up to five days a week.

Service Limitations:

Per the identified need as included in the individual's Plan of Care:

• SADC services shall be provided for at least five consecutive hours daily, exclusive of any transportation time, up to five days a week
• SADC is not available to those residing in an ALF as it would duplicate services required by the Assisted

• Living Licensing Regulations
• SADC cannot be combined with Adult Day Health Services
• The individual has no specific medical diagnosis requiring the oversight of an RN while in attendance at the SADC
• ALP participants, not ALR or CPCH participants, may attend SADC two (2) days a week
• AFC participants may attend SADC two (2) days per week

Provider Specifications:

The provider must be a Medicaid-approved entity that meets the following qualifications:

• Facility that (a) has a license or occupancy permit available, (b) has police and fire department response agreements, and (c) has written safety and emergency management policies and procedures
• Personnel: (a) program director designated, (b) has adequate staff to meet program needs of target population, and (c) and at a minimum, has identified a nurse consultant
• Client population: established criteria for target population based on resources and program capabilities of facility
• Program activities: planned and ongoing age appropriate activities based on social, physical and cognitive needs of the target population
• Individualized Plans of Care: based on identified individual client needs, jointly developed with client and family
• Social Services: coordination with, and referrals to, available community agencies and services. Staff has periodic contact with families
• Nutrition: provides a minimum of one nutritionally balanced meal per day. Special diet needs are met. Snacks provided as necessary
• Health Management: (a) an initial health profile is completed. (b) monthly weights are taken and other health-related observations are recorded as necessary
• Personal Care: personal assistance as needed with mobility and ADL
• Possesses business authority to conduct such business in New Jersey and is in compliance with all applicable laws, codes and regulations, including physical plant requirements, fire safety and ADA compliance

Speech, Language and Hearing Therapy (Group and Individual)

For the purpose of habilitation and the prevention of loss of function. This service is available only after rehabilitation is no longer available or viable.

MLTSS will include rehabilitation therapies for an individual with a TBI diagnosis. CPT codes are to be used for these services.

Service Limitations:

Per Medical Necessity as defined in the contract. MLTSS rehabilitation therapies for individuals with TBI diagnoses are limited to one session per day.

Provider Specifications:

• A rehabilitation hospital
• Community Residential Services (CRS) provider
• Licensed, certified home health agency
• Post-acute non-residential rehabilitative services provider agency

TBI Structured Day Program

A program of productive supervised activities, directed at the development and maintenance of independent and community living skills. Services will be provided in a setting separate from the home in which the participant lives. Services may include group or individualized life skills training that will prepare the participant for community reintegration, including but not limited to attention skills, task completion, problem solving, money management and safety. This service will include nutritional supervision, health monitoring and recreation as appropriate to the individualized Plan of Care.

Service Limitations:

The individual must have a diagnosis of acquired, nondegenerative TBI, or formerly a TBI waiver participant who is transitioning to MLTSS. The program will not cover services paid for by other agencies. The program excludes medical day care.

TBI Supported Day Services

A program of individual activities directed at the development of productive activity patterns, requiring initial and periodic oversight at least monthly.

The Supported Day Service is intended to be a home- and community-based service, not provided in an outpatient setting or within a Community Residential Service, although it may be provided by staff that work in either of these settings. The service supports a person's Plan of Care in a community setting, like volunteering, shopping, recreation, building social supports, etc. The activity is provided one to one, as opposed to a group home outing or group services provided in a structured program. Individuals tend to be either higher functioning and able to eventually do the activities they are being supported in independently, or lesser functioning, capable of such activities in the community with increased support.

Activities that support this service include but are not limited to therapeutic recreation; volunteer activities; household management; shopping for food, household goods, clothing; negotiating various components of activities in the community; and building social supports in the community.

Service Limitations:

The individual must have a diagnosis of acquired, non-degenerative TBI, or formerly a TBI waiver participant who is transitioning to MLTSS.

Supported Day Services are provided as an alternative to a Structured Day Program when the participant does not require continual supervision. Services are not to be provided in a setting where the setting itself is already paid to supervise the participant. Limits in service should be delineated by assessment of the person receiving the service, as directed by the master's level rehabilitation professional. The amount, frequency and duration of this service are determined by the recommendation made by the qualified professional. The Care Manager develops the Plan of Care, taking the professional's recommendations into account when developing the total service package necessary to maintain the participant in the home/community environment.

Provider Specifications:

A professional holding at least a master's degree in a rehabilitation-related discipline (including but not limited to; psychology, social work, PT, OT, SLP, nursing, CRC, etc.) to sustain the program. This service may be provided by rehabilitation staff at the paraprofessional level (minimum of 48 college credits) or higher, and the program and service providers will receive ongoing supervision from a licensed or certified professional at a minimum, in addition to the clinical oversight provided by the aforementioned master's level rehabilitation professional. Registered nurses (NJSA 45:11-26) and licensed clinical social workers (NJSA 45:1-15) may provide this service when employed by an approved provider agency such as a mental health agency or family service agency. Licensed, clinical social worker may provide this service if under the supervision of a psychologist.

The following services are state plan services that would be beneficial to the support of a MLTSS member. In developing Plan of Care for a member the services below should be considered.

• Medical Day Services – Pediatric and Adult
• As specified at N.J.A.C. 8:86 (five hours per day/five days per week)
• MLTSS PCA